Refeeding Syndrome: An Important Complication Following Obesity Surgery

Dual Hepatic Injury from Refeeding Syndrome and Starvation in a Malnourished Woman After Bariatric Surgery: A Case Report

BACKGROUND Refeeding syndrome (RFS) and starvation-associated injuries are significant complications in malnourished patients. Severe weight loss after obesity surgery is frequently associated with malnutrition, consequently increasing the likelihood of RFS and starvation-related injuries as postoperative complications. RFS and starvation-induced injury in a single patient has rarely been reported. In this paper, we present, for the first time, a case of hepatic injury attributed to both refeeding syndrome and starvation-induced hepatic injury in a malnourished woman following bariatric surgery. CASE REPORT A 27-year-old female patient was admitted to the hospital for severe malnutrition after sleeve gastrectomy. Her body mass index (BMI) dropped from 37.2 kg/m² to 12.4 kg/m² 1 year after surgery. After nutritional supplementation, her liver enzymes levels increased significantly, with severe hypophosphatemia suggesting the development of RFS. During the calorie restriction treatment for RFS, the patient unexpectedly exhibited the recurrent increase of liver enzyme levels and severe reduction in body weight, albumin, and hemoglobin, which is considered to be caused by starvation-induced injury during the treatment of RFS. Following precise nutritional re-supplementation, her liver enzyme levels were dramatically decreased, with significant elevated hemoglobin and albumin levels at discharge and during the follow-up visit. CONCLUSIONS Chronic malnutrition and extreme weight loss can occur following bariatric surgery. Our report highlights the potential for RFS and starvation-related liver injuries as postoperative complications for high-risk patients after bariatric surgery. Liver injury can occur in both RFS and starvation-induced hepatitis. Nutrition initiation and supplementation should be carefully balanced in high-risk patients during nutritional treatments.

One Page in the History of Starvation and Refeeding

There is a long history of starvation, including reports dated back to antiquity. Despite exceptional scientific developments, starvation still exists today. The medical aspects of starvation were well established in the twentieth century, particularly following studies related to the 1943-1944 Bengal famine in India and starved prisoners of war and survivors of World War 2. The refeeding of the starved victims provided disappointing results. Nevertheless, those studies eventually led to the development of a new branch of research in medicine and to the definition of what is now known as refeeding syndrome. This paper briefly reviews the history and groundwork that led to today's understanding of starvation and refeeding, with a particular emphasis on the observations from studies on starved Holocaust survivors and prisoners of war after World War 2. The relevance of these studies for modern times is briefly discussed.

A case of life-threatening, early postoperative refeeding syndrome in an obese young female undergoing laparoscopic sleeve gastrectomy

Early complications after a laparoscopic sleeve gastrectomy (LSG) include bleeding, leaks, strictures and bowel obstructions. Patients post-LSG experience rapid but intended weight loss and may be on a restricted diet before and following surgery. Thus, many of these patients are in a malnourished state, placing them at a risk of developing potentially life-threatening refeeding syndrome (RFS). We describe the case of an 18-year-old female who developed RFS 2 weeks after LSG. We examine potential causes, review literature and discuss RFS pathophysiology as well as the guidelines that could help prevent RFS in bariatric surgery. Currently, not much is known about the risk of RFS in bariatric surgery and to our knowledge, this is the first report of RFS occurring in the early postoperative phase after LSG. A globally accepted definition of RFS should be established for guidelines to encompass wider patient groups.

The incidence of cardiac arrhythmias during exercise stress testing: a focus on patients with severe obesity undergoing sleeve gastrectomy

INTRODUCTION

Obesity is associated with a higher risk of cardiac arrhythmias. Sleeve gastrectomy (SG) is a common bariatric surgery with beneficial effects on weight loss and comorbidities. The study aimed to investigate the prevalence of arrhythmias during maximal exercise testing in patients with moderate-severe obesity and to evaluate the impact of SG on these arrhythmic events.

METHODS

All patients with moderate or severe obesity who were considered suitable candidates for SG between June 2015 and September 2020 were recruited. Each patient underwent three incremental, maximal, ECG-monitored cardiopulmonary exercise test 1 month before and 6 and 12 months after SG; the frequency and complexity of ventricular premature beats (VPBs) and atrial premature beats (APBs) have been evaluated during rest, exercise and recovery phases.

RESULTS

Fifty patients with severe obesity (BMI 46.39 ± 7.89 kg/m²) were included in the study. After SG, patients presented a decreased BMI (34.15 ± 6.25 kg/m² at 6 months post-SG and 31.87 ± 5.99 kg/m² at 12 months post-SG). At 6 months post-SG, an increase in VPBs, mainly during the recovery phase, was observed. At 12 months post-SG, a reduction in VPBs compared with the 6 months evaluation was showed.

CONCLUSION

Although in the early post-surgical phase the risk of exercise-induced arrhythmias may be higher, SG does not seem to increase the occurrence of arrhythmias in the long-term. No life-threating arrhythmias were found during post-SG evaluations.

Refeeding syndrome in surgical patients post initiation of artificial feeding, a prospective cohort study in a low-income country

BACKGROUND & AIMS

South Africa's inequitable history has contributed to a malnourished population, further aggravated by high levels of violence and economic uncertainty culminating in a population suffering the sequelae of poverty. The perceived notion is that malnutrition places the South African population at greater risk for development of refeeding syndrome. This study aimed to identify the incidence of refeeding syndrome in the South African population.

METHODS

All patients admitted into the surgical intensive care unit from 1 November 2019 to 30 September 2020, were screened using the National Institute for Health and Care Excellence (NICE) refeeding risk criteria. Patients started on artificial feeds with one or more risk factors were included in the study. The syndrome was confirmed using the King's College criteria and compared with the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for refeeding syndrome.

RESULTS

200 Patients were included in this study. The median age of the sample population was 41 years (IQR 30-58) with a male predominance (63%). All patients included had one or more risk factors and 62 (31%) of patients fulfilled the NICE criteria. The sensitivity of the NICE criteria was 33% and specificity was 70%. The most common risk factors identified were little or no nutritional intake for >5 days (55%) followed by a history of alcohol abuse, drugs including insulin, chemotherapy, diuretics or antacids (18%). Specificity values for all risk factors were >80% apart from little or no nutritional intake for >5 days which had a specificity of 64.2%. Sensitivity values for all risk factors were low. 84.5% of patients received artificial nutritional support in the form of enteral feeds, 9% parenteral and 6.5% both enteral and parenteral feeds. A total of 146 patients required electrolyte supplementation. Three patients fulfilled the King's College criteria and one subsequently died. In comparison, 25 patients fulfilled the ASPEN criteria and 3 demised.

CONCLUSION

Due to the low sensitivity and specificity of the NICE criteria, we advise that it be used merely as a guideline to identify patients at risk of refeeding syndrome and one should remain vigilant in patients with any risk factors present. Due to the small number of patients who fulfilled the King's College criteria and significant difference in incidence when compared to the ASPEN definition, a conclusion regarding the accuracy of both diagnostic criteria could not be made. We recommend a review of the current definition and a global adoption of an agreed criteria for the estimation of the true prevalence.

Pathophysiology, prevention, and treatment of beriberi after gastric surgery

Beriberi is a nutritional complication of gastric surgery, caused by deficiency of vitamin B₁, or thiamine. Thiamine deficiency leads to impaired glucose metabolism, decreased delivery of oxygen by red blood cells, cardiac dysfunction, failure of neurotransmission, and neuronal death. This review describes the history and pathophysiology of beriberi as well as the relationship between beriberi and nutritional deficiencies after gastric surgery. A literature review of the history and pathophysiology of beriberi and the risk factors for thiamine deficiency, particularly after gastric resection or bariatric surgery, was performed. Recommendations for nutritional follow-up post gastric surgery are based on current national guidelines. Patients may have subclinical thiamine deficiency after upper gastrointestinal surgery, and thus beriberi may be precipitated by acute illness such as sepsis or poor dietary intake. This may occur very soon or many years after gastrectomy or bariatric surgery, even in apparently well-nourished patients. Prompt recognition and administration of supplemental thiamine can decrease morbidity and mortality in patients with beriberi. Dietary education post surgery and long-term follow-up to determine nutritional status, including vitamin and mineral assessment, is recommended for patients who undergo gastric surgery.

Treatment of liver failure post one anastomosis gastric bypass by revising to normal anatomy: A case report

Introduction

Obesity and the associated metabolic syndrome are global health problems. Significant weight loss after bariatric surgery can cause a substantial difference in those comorbidities in obese patients. In this case, we described a rare complication of a patient who developed acute liver failure after an uneventful one anastomosis gastric bypass treated conservatively and revision of the one anastomosis gastric bypass to normal anatomy.

Case presentation

We present a 52-year-old female known to have hypothyroidism and morbid obesity with a BMI of 45. For that, she underwent uneventful one anastomosis gastric bypass. Later, she developed liver failure and hepatic encephalopathy, which was managed conservatively and revision surgery to normal anatomy.

Discussion

Bariatric surgery plays an integral role in treating obese patients for its associated impacts, like facilitating weight loss and related metabolic syndrome improvement. The effects of bariatric surgery on liver functioning are controversial. Some malabsorptive procedures are linked to postoperative hepatic complications. However, it is uncommon in a recent new technique in bariatric surgery. Liver transplant and revision of the bariatric surgery have been described as management. However, optimal nutrition support without a liver transplant along with revision surgery is possible in experienced hands.

Conclusion

Early detection of liver impairment and early intervention by a revision to normal anatomy by an experienced surgeon is considered the safest and most effective procedure for such patients. However, late detection where liver failure occurs, liver transplantation is the only effective treatment for preventing fatal outcomes.

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Revision of one anastomosis gastric bypass as a treatment for liver failure

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Optimizing the nutritional status is essential in revision surgeries.

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Monitoring of liver status post-bariatric surgery is important.

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An experienced bariatric surgeon should do the revision surgeries.

Reversal to normal anatomy after one-anastomosis/mini gastric bypass, indications and results: a systematic review and meta-analysis

This review evaluates the indications and outcomes of one-anastomosis/mini gastric bypass (OAGB/MGB) reversal to normal anatomy. A systematic literature search and meta-analysis was performed in PubMed, Web of Science, and Scopus for articles published by October 1, 2020, including the keywords "one anastomosis gastric bypass," "OAGB," "mini gastric bypass," "MGB," "reversal," "reverse," "malnutrition," and "reversal bariatric surgery". After examining 182 papers involving 11,578 patients, 14 studies were included. A reversal was performed in 119 patients on average 23.6 months after the primary OAGB/MGB surgery. The mean body mass index (BMI) was 22.92 ± 3.47 kg/m² and the mean albumin level was 25.17 ± 4.21 g/L at reversal. The mean length of the common channel (CC) was 383.57 ± 159.35 cm, with a mean biliopancreatic limb (BPL) length of 214.21 ± 48.45 cm. Pooled estimation of the meta-analysis of prevalence studies reported a prevalence of 1% for reversal. The major signs and symptoms of protein-energy malnutrition were the leading causes of the reversal of OAGB/MGB. Bleeding, leakage, and death due to severe liver failure were the most reported complications after reversal, with an overall incidence of 10.9%. In conclusion, OAGB/MGB reversal has a prevalence of 1% and has a complication rate of 10.9%. Protein-energy malnutrition with hypoalbuminemia was the most common etiology. The mean lengths of BPL and CC were reported as 215 cm and 380 cm, respectively, in the cases. Therefore, special attention should be paid to malnutrition in all OAGB/MGB patients during follow-up to prevent severe malnutrition and subsequent increase in reversal procedures.

Refeeding syndrome: multimodal monitoring and clinical manifestation of an internal severe neurotrauma

Refeeding syndrome (RFS) is a rare, potentially life-threatening, condition seen in malnourished patients starting refeeding. RFS may provoke seizures and acute encephalopathy and can be considered an internal severe neurotrauma in need of specific treatment. The objective was to describe course of disease, treatment and, for the first time, multimodal monitoring output in a comatose patient suffering RFS. After gastric-banding and severe weight loss, the patient initiated self-starving and was transferred to our intensive care unit (ICU) following rapid refeeding. At arrival, seizures, decrease in consciousness (GCS 7) and suspected acute encephalitis was presented. Serum albumin was 8 g/l. Intracranial pressure (ICP), invasive blood pressure and electrocardiography (ECG) were monitored. Pressure reactivity (PR_x) and compliance (RAP) were calculated. The patient developed congestive heart failure, anuria and general oedema despite maximal neuro- and general ICU treatment. Global cerebral oedema and hypoperfusion areas with established ischemia were seen. ECG revealed massive cardiac arrhythmia and disturbed autonomic regulation. PR_x indicated intact autoregulation (-0.06 ± 0.18, mean ± SD) and relatively normal compliance (RAP = 0.23 ± 0.13). After 15 days the clinical state was improved, and the patient returned to the primary hospital. RFS was associated with serious deviations in homeostasis, high ICP levels, ECG abnormalities, kidney and lung affections. It is of utmost importance to recognize this rare syndrome and to treat appropriately. Despite the severe clinical state, cerebral autoregulation and compensatory reserve were generally normal, questioning the applicability of indirect measurements such as PR_x and RAP during neuro-intensive care treatment of RFS patients with cerebral engagement.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Preventing Wernicke Encephalopathy After Bariatric Surgery

Half a million bariatric procedures are performed annually worldwide. Our aim was to review the signs and symptoms of Wernicke's encephalopathy (WE) after bariatric surgery. We included 118 WE cases. Descriptions involved gastric bypass (52%), but also newer procedures like the gastric sleeve. Bariatric WE patients were younger (median = 33 years) than those in a recent meta-analysis of medical procedures (mean = 39.5 years), and often presented with vomiting (87.3%), ataxia (84.7%), altered mental status (76.3%), and eye movement disorder (73.7%). Younger age seemed to protect against mental alterations and higher BMI against eye movement disorders. The WE treatment was often insufficient, specifically ignoring low parenteral thiamine levels (77.2%). In case of suspicion, thiamine levels should be tested and treated adequately with parenteral thiamine supplementation.

Problems in bariatric patient care - challenges for dieticians

Obesity management options include a low-calorie diet, behavioral therapy, regular physical activity and pharmacological therapy. However, treatment failure is frequently encountered, most of these methods are ineffective, and a positive outcome is rarely maintained in the long term. In morbidly obese patients, bariatric surgery is considered the most effective treatment for obesity as well as the accompanying diseases. Bariatric surgery promotes much greater weight loss than conservative treatment, regardless of the applied surgical technique. Bariatric surgery patients should receive professional perioperative (preoperative, intraoperative and postoperative) care from a multidisciplinary team of specialists, including a bariatric surgeon, a general practitioner, a dietitian and a health psychologist. Patients require postoperative nutritional counseling to be able to stabilize their weight and maintain long-term weight loss after surgery. Patients are guided by bariatric dietitians through the process of adopting new eating habits and behavior, learning how to make healthy food choices.

Should bariatric surgery be performed in adolescents?

Adolescent obesity has markedly increased worldwide in both its extent and prevalence in recent decades and obesity prevention strategies are failing. As a result, effective treatment strategies are urgently needed. As behavioral and pharmacological treatment approaches have only moderate effects in severe obesity, bariatric surgery has begun to emerge as a treatment option. In this debate article, we offer arguments opposing and supporting bariatric surgery in the treatment of severe obesity in adolescents. Bariatric surgery has superior therapeutic outcomes with respect to weight loss and resolution of comorbid diseases over other existing treatments. However, long-term outcomes after bariatric surgery in adolescents are only just beginning to emerge. Furthermore, the procedures are generally considered irreversible, apart from gastric banding. Most importantly, not all adolescents seem to benefit greatly from bariatric surgery and we are not yet able to reliably identify those who stand to gain the greatest benefit. The authors agree that adolescent bariatric surgery should be offered exclusively within formal adolescent obesity programs, delivered by specialist multidisciplinary child/adolescent obesity teams, and within specialist centers, in order to optimize outcomes and minimize potential detrimental effects. Patients and their family/carers must be educated regarding the benefits and risks, potential side effects, expected changes in eating behavior and the lifelong requirement for regular medical follow-up after surgery. Before embarking upon a surgical treatment pathway in adolescents with severe obesity, it may also be beneficial to ensure compliance to treatment is demonstrated, in order to minimize the risk of nutritional deficiencies and associated potential complications.